January / February 2006Evidence-Based MedicineThe Evolution of Evidence-Based Medicine

By Susan Walker, MBA

Though more than 50 million people use the Internet to access health information (Fox & Rainie, 2000), lack of quality control and ease of posting allow Web-based healthcare to pose a potential for harm. The solution is to use evidence-based medical content as a standard that addresses the professional requirements of physicians and the practical needs of consumers. Evidence-based medicine (EBM) can reduce costs, variability of care, and errors for hospitals and physicians, as well as provide a credible source of health information for patients and consumers.

What Is Evidence-Based Medicine?We are at the inception of a new era of medicine. In the past, most physicians used their experience and knowledge to guide health decisions. When a clinical question arose at the point of care, physicians relied on textbooks, literature searches, and even pharmaceutical representatives to get the information and answers they needed. The physician would then select the most relevant article from the results, evaluate the research, and determine what to do next  a time-consuming and inefficient activity.

EBM has always tapped clinical research to guide health decisions. It is the explicit use of the best available evidence to support decisions about the care of an individual patient. The British Medical Journal defines EBM as "integrating individual clinical experience with the best available external clinical evidence from systematic research" (Sackett, et al., 1996). Today's online EBM solutions are faster, have broader and deeper reach into the plethora of medical literature produced, and can quickly cull and provide the most current information on a particular condition from leading physicians in the field.

Though the concept of EBM has been around for 3 decades, only in the past 3 years has it become an imperative for hospitals and clinicians. Its newly found popularity has been driven by a number of factors including the explosion of clinical knowledge, increases in health costs, rising patient expectations, and technology's evolving sophistication. Technology-enabled EBM is poised to improve patient care by making specific data within the avalanche of new medical information accessible to physicians when they need it for critical point-of-care decisions.

To realize the Internet's potential as a universal health information resource, it is incumbent on the healthcare community to make EBM the standard for online information. This long-term initiative, to develop and provide EBM for all conditions, with information important to physicians and useful to consumers, must begin with the medical community's adoption of evidence-based content at the point of care. Though there is some common knowledge among consumers about EBM, it is not considered a de facto standard by the general public seeking health information on a given condition. EBM will only be considered a "given" when it is commonly used by the majority of medical professionals (physicians and clinicians) during their daily point-of-care practice. Online EBM directed at consumers provides a less technical, easier to understand description, though still with evidentiary references provided as back-up.

Online Healthcare Information and ConsumersResearch shows that people put more credibility in information retrieved from the Internet than from any other media (Hawkins, et al., 1987). A 2004 study indicated that 51% of all adults in the United States, or some 111 million people, go online for health-related information. This number was up from 54 million in 1998 (Taylor, et al., 2004). Also, 52% of consumers who sought health information on the Internet report that they think "almost all" or "most" of the health information they see on the Internet is credible (Fox & Rainie, 2000).

The Federal Trade Commission (FTC) estimates that only about half of the content on health and medical Web sites has been reviewed by physicians (Fox & Rainie). Since there is no quality control of online health information, consumers may find a number of conflicting views on the same subject.

For example, Impicciatore, et al. (1997), evaluated the reliability of information found on 41 Web sites about managing fever in children at home. Only four Web sites presented information that closely adhered to medically established guidelines. Another study analyzed 443 Web sites that contained information about the 8 best-selling herbal dietary supplements and found that more than half of them made illegal health claims (Morris & Avorn, 2003).

Health information that is incomplete, inaccurate, or misleading can be harmful. If patients act on it, they might harm themselves or delay seeking medical attention until a treatable problem has become life threatening. Of the estimated 21 million people who seek health information on the Internet, 70% said the information influenced their decision about how to treat an illness or condition, and 28% said it influenced their decision about whether or not to see a doctor (Fox & Rainie, 2000).

When seeing a doctor, many consumers use online information to facilitate their physician/patient encounter. The Health On the Net Foundation (2001) found that 64% of patients who sought out health information on the Internet discussed their findings with their physician. In the same survey, 43% used the Internet to seek a second opinion, and 61% reported that consultations with their physician were more constructive after acquiring health information online. Also, if patients find online information that conflicts with the information or treatment they receive from clinicians, their trust in the healthcare system could be permanently damaged (Robinson, et al., 1998).

The Challenges Facing EBMIn order for health information online to be as useful to consumers and patients as they expect it to be, EBM must become a standard for healthcare practice. The path to this kind of a standard starts with hospital and physician use. Embedding EBM within technology systems reinforces its use and is a critical next step in the evolution of EBM.

Experts agree that translating medical evidence into quality clinical care must involve IT. In Crossing the Quality Chasm, the Institute of Medicine (IOM) called for providers, payers, and consumers to adopt EBM as the standard for quality of care. Further, the IOM stated that in order for healthcare delivery to be transformed, IT must play a key part (IOM, 2001).

Multiple studies have also demonstrated that technology-enabled EBM can improve physician performance and patient outcomes by providing physicians with practical tools at the point of care (Chertow, et al., 2001; Raschke, et al., 1998; Johnston, et al., 1994). Though in theory most physicians are in favor of EBM, some of the realities of current-day practice create an environment in which it is difficult for them to contemplate the degree of change that EBM represents:

Seeing more patients leads to having less time available per patient.

Difficulty in accessing critical information that is often fragmented and dispersed.

Greater complexity in treatment with more drugs, therapies, and surgical procedures.

Lack of appropriate technology to find the "nugget" of information when and where they need it most  at the point of care.

Additionally, there have been studies demonstrating the healthcare system often falls short on its ability to translate knowledge into practice. RAND Corporation issued a report in 2003 noting that evidence-based guidelines are followed by clinicians in less than 55% of patient diagnoses (Shekelle, et al., 2003).

The cost of non-adherence to evidence-based care is clearly laid out by Shortell, et al. (2003), "Large physician groups are using only one-third of recommended care-management processes for asthma, congestive heart failure, depression, and diabetes. The four conditions account for about 140,000 deaths and more than $143 billion in costs each year in the U.S."

Toward the Practice of Technology-Driven EBM CareHospitals need a road map that benchmarks where they are today and provides a plan of action describing near- and long-term goals. Evidence-based tools should be made part of that action plan and must fit within the workflow of the physician.

The objective is to assist the physician in making the best clinical decision and in following recommended practices throughout the care delivery process. The key question should be, where do we start, and given the options, what should we focus on?

Getting StartedThere are certain approaches that can make the EBM adoption process easier for hospitals to embrace. These include:

Identify stakeholders and determine culture for EBM.

Establish long- and short-term goals.

Select appropriate content and tools.

Ensure the technology is easy to use.

Measure against established goals.

StakeholdersIdentify stakeholders to determine specific goals and objectives. Determine which organizational leaders need to be part of the strategy and assign tasks for each to champion. Leaders within the organization must accept the value of EBM as a tool to improve operational performance and clinical outcome and get behind the strategy. Clinicians can also make or break a hospital's efforts to implement evidence-based medicine and should be involved in the strategy early on to ensure they see it as a benefit to patients and that it aligns with their workflow.

It is important to involve doctors as stakeholders. "By involving physicians early in the process, they are already migrating decisions against a predetermined mean and increasing quality without changing routines all at once," said Dr. Steven Merahn, a vice president at Albert Einstein Healthcare Network.

Long- and Short-Term GoalsBenchmark where the organization is today against its long- and short-term goals. A number of factors may be considered when establishing goals that tie to evidence-based medicine including strategies such as pay-for-performance or tying accreditation to the implementation of specific evidence-based measures.

For example, financial incentives may be tied to how well physicians adhere to evidence-based standards. Those who utilize tools such as evidence-based guidelines and order sets within their daily workflow may be rewarded if they meet or exceed the benchmark set by regulatory bodies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS).

In a study by Woolf, et al. (1999), using recommended guidelines helped to avoid harmful consequences. When a patient comes into the emergency department with symptoms indicating a pre-heart attack condition, a technology-driven EBM solution would suggest getting aspirin into the patient's system quickly, or it might suggest the option of using a beta-blocker. These prompts are a way of not only reminding physicians to do things quickly, but also to look to evidence in support of their decision. This same study states that 39% to 55% of possible heart attack patients did not receive these essential medications, resulting in an estimated 37,000 deaths.

Perhaps the Holy Grail of evidence-based healthcare will be achieved when evidence-based health services are partnered with evidence-driven health management and public policy initiatives (McQueen, 2001).

Appropriate Content and ToolsStart with relevant clinical information such as evidence-based guidelines, order sets, safety checklists, and alerts. Many physicians and healthcare organizations find the creation and maintenance of order sets to be too time-consuming to do internally. Systems that offer customizable evidence-based tools are beneficial as a turn-key system or as templates to jump-start your strategy. Another way to practice EBM is to partner with a credible and independent third-party source of timely, evidence-based tools. It is important to look for a solution that grades the evidence, filters the information and literature, provides alerts when significant new evidence is presented, and allows for editing and customization of the EBM tools that will be deployed.

Ease-of-Use for Acceptance and AdoptionIt is essential that certain questions be answered when evaluating ease-of-use for acceptance and adoption of EBM tools. How much flexibility does the system offer to the organization? Does it offer administrative tools that engage senior management and providers, giving all participants a stake in the success of the program? Can the evidence and tools be tied to quality measures from organizations such as JCAHO, CMS, and NQF to facilitate compliance of your organization with these accreditation bodies?

Systems that deliver evidence-based information and tools in an easy-to-implement, scalable fashion can also become the building blocks for an organization to set processes and a path toward other health IT initiatives such as computerized physician order entry (CPOE).

Measure Against GoalsValidate and measure results against the goals. For instance, obtain an agreement from physicians that for any patient with chest pain, certain decisions will be benchmarked against an outside, evidence-based reference source.

Finally, don't lose sight of the individual patient. Ensure the deployed system offers tools that facilitate communication and collaboration between the clinician and patient. JCAHO's patient-focused "Speak Up" campaign encourages patients to "become active, involved, and informed" about their diagnosis and treatment plans. Look for systems that offer information directed at the patient.

For example, if a patient needs a knee replacement, though he or she may have indicated understanding of the procedure after a verbal explanation from the doctor, that understanding may not be thorough. An additional information resource for the patient could be a Web-based multimedia tutorial that provides clear, evidence-based definitions of the critical features, rationales, and risks of the anticipated knee replacement procedure.

Improving Health and Healthcare with EBMThe availability of technology-driven EBM will have a profound effect on the behavior of health professionals. With real-time entry of clinical notes and orders there comes the need for real-time, context-based evidence. Reference information must be accessible at the point of care and allow the clinician to hone in on just the pieces of information needed for a specific patient at a specific point in the workflow. This must happen with a couple clicks of the mouse. Gone will be the days when a clinician has the time or the inclination to leaf through a book or to scan a list of results from a search engine. In the new world of high-tech medical practice, the more integrated the evidence and clinical tools are within the workflow of the professional, the higher their value to the practitioner.

As EBM becomes more easily accessible to the professional medical community through networked applications, tools, and online resources, its use as a medical information standard for consumers will become more accepted. As this occurs, EBM will begin to fulfill its potential as a trusted resource for health information for all.

To offer comment and/or learn more about the subject, contact HealthGate Data Corp.'s marketing director, Dean Wetherbee, at 781-685-4105 or dwetherbee@healthgate.com. HealthGate is a provider of evidence-based guidelines, tools, and applications.

Impicciatore, P., Pandolfini, C., Casella, N., & Bonati, M. (1997). Reliability of health information for the public on the World Wide Web; Systematic survey of advice on managing fever in children at home. British Medical Journal, 314.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C.: National Academy Press.